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| Gary Wendt, MD, MBA |
Gary J. Wendt, M.D., MBA, is a Professor of Radiology, and Enterprise Director of Medical Imaging and Vice Chair of Informatics at the University of Wisconsin-Madison. He has more than 20 years experience in electrical and computer engineering, business, internal medicine and radiology. Dr. Wendt began his career as a computer scientist where he wrote several copyrighted applications for large commercial institutions. A frequent speaker at conferences, he spoke at the SIIM Wisconsin Regional Meeting last October. He outlined the UW Medicine experience in implementing a multi-organizational, multi-modality PACS. As part of that project Dr. Wendt and his colleague at UW, Dr. Richard Bruce, spun off a company to develop a software system called ImageMoverMD that makes it easy for physicians and other providers to upload images captured from mobile devices to a PACS that is DICOM compatible and feeds into to the patient’s EMR.
Q. Can you give me a sense of the scale of the UW Medical System?
Our total exam volume for the PACS system is about a 1 million exams a year, about 65 percent of that is UW the rest is other organizations. We have Children's Hospital, the main UW hospital, and a third hospital on the eastside of Madison and about 85 clinics.
Q. What was the situation before you started implementing multi-site, multi modality PACS?
The big driver is the amount of patient flow between sites. That was the initial impetus to do this. There was a large primary care hospital in town and we're a large tertiary care hospital and patients flow between those as we both treat different things. Another was the large HMO in town. They are primary care focused, and they refer to both the primary care and the tertiary care hospitals. So that was the prime driver to implement this multi-organizational PACS.
That is one of the first questions an administrator should ask. Just because there are two hospitals, unless there is a significant cross flow of patients it probably isn't going to be worth the effort, because it is not as simple as just turning it on. You have to make sure you have interface engine in place, get a master patient index, linking and all the rest of it. If there isn't a clear benefit, I wouldn't even try doing it.
Q. How did you go about building a regional multi-organization image sharing system?
The multi-departmental PACS was actually easier, low hanging fruit. We had endoscopy, GI, ENT, OR, OB, and we have pathology, ophthalmology, cardiology, radiology. Going after all those different ‘ologies’ is actually pretty low-hanging fruit for most organizations, because getting all these different things into one site, into one bucket, one viewer is pretty useful, because you are always going to have patients flowing between departments. So that is much lower hanging fruit.
For multi-site image exchange some of the earliest stuff we started with was regional hospitals and clinics that were sending us lots of CD’s so we targeted them for digital network based image exchange. After that we worked with one of the larger HMOs in town and then with another hospital in town.
Q. What were the challenges you faced related to mobile devices?
One of the biggest challenges we had, when we looked around at providers, a large percentage of them had patient photos on their mobile devices so we decided it was time to do something. Realistically, in terms of mobile device image capture, I have a feeling that in all likelihood its image volume will eventually surpass radiology in volume. There are so many different use cases. Post-operative wound care, and even more subspecialty uses, there is documentation of things like pressure ulcers, to make sure you get reimbursement for care of pre-existing wounds, there are so many use cases. I think mobile device, visible light imaging is probably going to be equal to or greater in magnitude than all other imaging modalities.
So we actually looked for a mobile device image acquisitioner. We looked and looked and couldn't find anything so eventually we spun off a company to develop an app that would offer a totally secure footprint, something that was 100 percent EMR integrated, PACS integrated, something that was easier to use than your mobile phone. It had to be easier than capturing images and leaving them on your phone. So we ended up developing an application that would capture the image and send to the PACS in a secure mode with no PHI ever residing on the mobile device.
Q. How does it work?
It is integrated with electronic medical records with the encounter ID, so that the image is linked into the medical record but then the images are archived on the PACS or VNA so it is just like entering other radiology images into the PACS or VNA. For example, the primary care physician has a patient with an unexplained rash. The doctor clicks a button in the EHR to display a QR code, launches the image app on the phone and points it at the QR code, and then takes a picture of the rash. The image link is immediately sent to the EHR for that patient and the image is stored on the PACS or VNA with all the necessary patient identification.
Q. So this app turns mobile device images into DICOM compatible images?
Yes absolutely with all the appropriate header information so that it goes directly into your vendor neutral archive and gets archived just like all your other exams.
Q. Do you have to take photo of the QR code for each picture?
No, just once per encounter. After the physician takes the pictures the software marries the picture to the patient's demographics and then forwards them to the PACS or VNA and then the PACS or VNA sends the HL7 message back to the EHR to close the loop and create the link.
Q. How is security managed?
The images are stored on the memory on the phone and are deleted after the app sends them to the server, and after the server sends them to the PACS, the images are deleted from the server and finally stored securely on the PACS.
Q. Is the system available to other institutions, or is it exclusive to UW Medicine?
The product has been in development for about two years and we have been commercializing it for the last year-and-a-half, it is not a part of the UW. It has also been installed at Marshfield Clinic, which is known for being an innovator in healthcare IT technology.
Q. Are there other vendors with similar capability?
No we looked long and hard and couldn't find anybody that had a really easy-to-use and secure solution. There were a couple that had ways to copy images from your phone into the archive, but often times you had to log in, you had to have VPN, and you had to look up a patient ID and create an order, and so on. It was a 15-minute process, and the bottom line is, physicians are not going to do that. They are going to snap a picture and leave it on their phones, and that is not really what you want.
Q. How was it rolled out and implemented on all your providers’ phones?
Locally we made it available to any provider. If you look at things like pressure ulcers, or central line monitoring that is documented by nursing or ancillary care staff. It is one of those things where a picture is worth a thousand words, you can type all you want but there are times when it is difficult to describe a discharge from a central line.
Q. How is the system purchased and installed?
The mobile capture app, ImageMover, is free. We sell the server software based on a subscription model that is priced according to the hospital’s size and volume.
Q. What are some of advantages for patient care?
As an example, say a patient presents in the ER with a sliver in the eye. You can take a picture of that with a mobile phone that can be entered into the patient’s EHR along with the x-ray. The radiologist seeing the visible light image side-by-side with the x-ray has a much better idea of where to look on the x-ray because wood is really hard to find on an x-ray. So the visible light image provides a much more complete picture of what is going on with that patient.
Q. What is the take-home message about implementing a multi-device, multi-organization imaging sharing system?
Two things, I think you should first go after internal imaging because you have by far a larger number of patients within your organization and if half the patient images are sitting on physicians’ telephones those are low hanging fruit. If you want to do multi-organization PACS I would take a good look at it and only do it if you really have a good patient care reasons. Are there truly patients flowing between the organizations? If there are, you probably get a big bang for the buck. If they are not, it probably isn't worth doing.
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